Prescription drug price updates that may affect Medicare Set Asides

To ensure the most accurate Workers’ Compensation Medicare Set-Aside (WCMSA) arrangement, we monitor RED BOOK® Average Wholesale Price (AWP) of the most common medications present in WCMSAs. This practice assists in identifying price changes, which may either positively affect settlement and provide savings, or increases that could hinder the settlement process and increase claims costs.

In the month of June, there were price changes for morphine sulfate tablets – both immediate release and extended release—brands MS Contin and Dilaudid, opioids commonly used for chronic pain. Products with price increases are relatively insignificant at less than 10 percent. However, the decreases are greater than 50 percent, and could provide savings on cases where these medications are prescribed.

The following products in the table have a change in AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Drug Name

NDC

Form

Strength

AWP Unit Price Change

Morphine Sulfate

42858-0801-01

ER Tablets

15mg

-$0.67

Morphine Sulfate

42858-0802-01

ER Tablets

30mg

-$1.48

Morphine Sulfate

42858-0803-01

ER Tablets

60mg

-$2.48

Morphine Sulfate

42858-0804-01

ER Tablets

100mg

-$2.09

Morphine Sulfate

00054-0235-25

Tablets

15mg

$0.08

Morphine Sulfate

00054-0236-25

Tablets

100mg

$0.14

MS Contin

42858-0515-01

ER Tablets

15mg

$0.43

MS Contin

42858-0631-01

ER Tablets

30mg

$0.82

MS Contin

42858-0760-01

ER Tablets

60mg

$1.61

MS Contin

42858-0799-01

ER Tablets

100mg

$2.38

Dilaudid

42858-0122-01

Tablets

2mg

$0.24

Dilaudid

42858-0122-01

Tablets

4mg

$0.37

Dilaudid

42858-0338-01

Tablets

8mg

$0.71

Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.

CMS uses the lowest AWP when reviewing WCMSA arrangements. The changes in price of these medications will immediately affect the prescription costs of WCMSA’s (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued). Optum will proactively contact clients when we have previously completed a WCMSA if we identify a significant impact to a case. It is our recommendation that carriers, TPA’s and claim handlers review their open cases to determine the affect these price changes may have on each individual claim.

If a price increase will adversely affect your case and preclude settlement, Optum has clinical mitigation products available to assist with lowering claim costs and aid in the settlement process.

Optum will continue to inform the industry of AWP pricing and other changes that may affect WCMSA arrangements.

This entry was posted in Medicare Set-Asides (MSAs), News Bulletins on by .

About Evelio Prieto, PharmD., RPh., CPh.

Evelio Prieto is a pharmacist and consultant pharmacist registered in the state of Florida. He is a graduate of the University of Florida College of Pharmacy where he earned a Doctor of Pharmacy degree in 1994. Evelio has worked as a pharmacist at Optum Settlement Solutions for four years. Prior to Optum, Evelio managed two local hospital outpatient and ambulatory infusion pharmacies (Tampa General Hospital and All Children’s Hospital John’s Hopkins Medicine). Prior to this, Evelio spent 15 years managing a Walgreens pharmacy. Throughout his career, he has worked with worker’s compensation and managed care Pharmacy Benefit Managers (PBMs) as well as Medicare Part B and D billing to ensure care for claimants in the community. Evelio served on the Florida Medicaid Drug Utilization Review Board from 2010 to 2015 and is part Optum’s Clinical Center of Excellence.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.